The present invention is directed to methods for administering health care resources amongst patients within a patient population and, more particularly, to generate a patient population and conserve the medical resources utilized to care for such population by utilizing methods that continuously monitor and evaluate health care delivery.
As is well known, the utilization of health care resources has and continues to be grossly inefficient. Generally, the current administration of health care in the United States is subject to tremendous abuse, both by patients, on one hand, and health care providers and health care providing institutions, on the other. With respect to the latter, it is well-known that health care providers and health care providing institutions, such as hospitals, clinical laboratories, outpatient and rehabilitation facilities, engage in capricious billing practices that enable such providers and institutions to charge for a multiplicity of services that may be available under a single clinical event. In this regard, to the extent a particular type of medical service is rendered by a professional provider, the same is typically identified by a CPT (Current Procedural Terminology) code, which describes the medical service by use of a numeric code utilizing an accepted method developed by the American Medical Association
Problematic with such practice, however, is that often times health care providers and health care providing institutions attempt to seek reimbursement, whether it be from an insurance company, health maintenance organization or government sponsored health care program, such as MediCare, for two or more separate services that are actually integrated into one clinical event. For example, the physician drawing blood for purposes of conducting lab work may attempt to have the procedure to draw blood charged separately and in addition to the services associated with the laboratory blood testing. Other well-known abuses occur when health care providers and institutions attempt to seek reimbursement for procedures and tests that are performed by non-physicians, such as nurses or technicians performing such procedures but seek reimbursement for the services of a physician.
Additionally wasteful practices include duplicative and unnecessary tests and procedures. Along these lines, many medical procedures are performed by specialists (who command higher rates of reimbursement) that oftentimes can be performed by a non-specialist, and in particular a patient's primary care physician. Likewise, many such procedures and tests are performed in an in-patient facility, as opposed to an out-patient facility, which thus substantially increases the costs associated with the applicable service. Furthermore, there is a tendency among health care providers and institutions to render care that fails to take into account lower cost alternatives that utilize cost-effective out-patient facilities, and/or competitive pricing practices that eliminate or substantially limit the utilization of specialists, the performance of unnecessary tests, excessive office visits, and the like.
In addition to health care providers and institutions, patients themselves contribute substantially to the cost and ineffective utilization of health care resources. As is well-known, patients can and frequently do seek unnecessary medical treatment or otherwise attempt to influence the judgment of the health care provider by demanding that unnecessary tests or procedures be performed, that the patients have access to specialists or particular medications, and/or seek in-patient services in situations where the patient's clinical condition clearly does not justify such level of care. Such potential abuses are particularly likely where patients are allowed the discretion to directly access specialists, as is typical in several well-known health care insurance plans, such as Blue Cross and Blue Shield, which thus bypasses the critical role played by the primary care physician in making an initial assessment of a patient's condition and whether the same truly warrants the attention of a particular specialist, and not to mention the specialist best suited to handle a particular condition.
In order to counter such wasteful and abusive practices by both health care providers, health care providing institutions, and patients, attempts have been made to implement certain practices and procedures to contain health care costs and conserve the utilization of health care resources. Exemplary of such attempts include requiring prior authorization and approval by an intermediate entity, such as a health maintenance organization or health insurance plan, to the extent a physician seeks to take a specified action, such as perform surgery, order a medical supply or refer the patient to a specialist. Also utilized are the practices of bundling, whereby a physician is paid a single payment for two or more medical services, and capitation whereby a health care provider is paid a set dollar amount as determined by a per member, per month calculation to deliver medical services to a specific patient population (i.e., members of a health maintenance organization). Still further examples include the use of preferred provider discounts, which encourage the use by patients of specific health care providers, and usual and customary reductions, which impose a reduction in the payment of medical services rendered as deemed justified by a health plan or insurance company based upon what is considered to be the justified value of such services as rendered in a particular geographical area.
Despite such attempts, however, there has yet to be devised any type of health care administration system or method that substantially conserves utilization of health care resources that as a consequence can dramatically lower the costs associated in providing care to a specific patient population. Such attempts have likewise failed to maintain any degree of consistent quality of health care insofar as prior art cost containment practices have been and continue to be riddled with “loopholes” and insufficient cost-deterrent mechanisms necessary to conserve and optimally utilize a finite amount of health care resources.
As a result of the aforementioned abuses and inefficiencies associated with the utilization of health care resources, the cost of health care has and continues to increase substantially while the quality of the health care provided has not necessarily improved. As such, there is a substantial need in the art for a health care administration method that is operative to effectively and efficiently utilize health care resources to administer care to a patient population as compared to conventional practices. There is additionally a need in the art to generate a patient population that takes into account a multiplicity of factors that facilitate the optimal utilization of health care resources utilized to care for a given patient population that is also continuously evaluated to maximize the efficient use of resources. There is still further a need in the art for such a method that substantially eliminates abusive billing practices, the performance of unnecessary procedures, the unnecessary use of specialists, minimizes utilization of out-patient and in-patient services, and is generally effective in eliminating the wasteful practices associated with the allocation and utilization of health care resources without adversely compromising clinical outcomes or quality of care.